SCOPE OF THE PROBLEM

Procedural sedation and analgesia (PSA) has been practiced in the emergency department (ED) for over 20 years. The safety and efficacy of ED PSA has been well established and the adverse event profile clearly delineated (Table 24-1).

Patient safety monitoring has been a key component of PSA beginning with electrocardiogram (ECG) and blood pressure measurements. In the 1990s, noninvasive oxygenation monitoring with pulse oximetry was introduced into PSA practice and, most recently, noninvasive ventilation monitoring with capnography.

The extent and frequency of safety monitoring is determined by the anticipated level of sedation (mild, moderate, deep, and dissociative). The level of sedation is determined by patient age (with young children typically requiring deeper sedation than adults for the same procedure), type of procedure (painful, mildly painful, and nonpainful), and duration of the procedure. These factors also help determine the drugs chosen and their route of administration.

CLINICAL ASSESSMENT

There are two types of monitoring used for ED PSA: interactive monitoring by ED personnel and mechanical monitoring through specialized equipment.

Interactive Monitoring

The key element of interactive PSA monitoring is continuous observation of the patient by an individual capable of immediately recognizing adverse events including respiratory depression, apnea, upper airway obstruction, laryngospasm, and vomiting. This person must be able to continuously observe the patient's face, mouth, and chest wall motion. Further, personnel should understand the pharmacology of PSA agents and be skilled in maintaining an airway and assisting ventilation.